Crohn's Disease: Abstracts - References
The following studies inspired our efforts and influenced our thinking. There has little progress in managing Crohn's disease since we first looked at the problem 25 years ago. Old dogma persists and prevails. We think we have identified a solution to the problem. We are not disappointed that we have not been offered the Nobel prize- yet. We realize that the recognition of important contributions often takes many decades.
Elemental diet as primary treatment of acute Crohn's disease.Author O'Moráin C; Segal AW; Levi AJ Source Br Med J (Clin Res Ed), 288: 6434, 1984 Jun 23, 1859-62
Acute exacerbations of Crohn's disease are usually treated with prednisolone or potentially more toxic immunosuppressive drugs or by surgery. In pilot studies replacing the normal diet by a protein free elemental diet also induced remission. A controlled trial was therefore conducted in which 21 patients acutely ill with exacerbations of Crohn's disease were randomised to receive either prednisolone 0.75 mg/kg/day or an elemental diet (Vivonex) for four weeks. Assessment at four and 12 weeks showed that the patients treated with the elemental diet had improved as much as and by some criteria more than the steroid treated group. Elemental diet is a safe and effective treatment for acute Crohn's disease. (See Alpha ENF)
Diet in the management of Crohn's disease.Author Workman EM; Alun Jones V; Wilson AJ; Hunter JO Source Hum Nutr Appl Nutr, 38: 6, 1984 Dec, 469-73
Thirty-three patients with Crohn's Disease were studied to see if their symptoms were related to food intolerances. Initial treatment to produce remission of symptoms was total parenteral nutrition (20), elemental diet (2) or elimination diet (11). Twenty-nine patients reported specific food intolerances, and 21 of these remained in remission on diet alone, the mean length of remission being 15.2 months. The most important foods provoking symptoms were wheat and dairy products.
Comparison of nitrogen utilization of two elemental diets in patients with Crohn's disease.Author Vaisman N; Griffiths A; Pencharz PB Address Division of Clinical Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada. Source J Pediatr Gastroenterol Nutr, 7: 1, 1988 Jan-Feb, 84-8 Abstract Energy, nitrogen absorption, and nitrogen utilization of two commercial elemental diets, Vivonex and Vital, were compared in 10 teenage boys and girls with Crohn's disease. The diets were given in random order as overnight feedings and were the sole source of nutrients for two consecutive periods of 3 weeks each. Urine and stools were collected for 48 h at the end of each 3-week period. Energy absorption was slightly better on Vivonex (p less than 0.05), although 95-100% of energy was absorbed with both formulas. Nitrogen absorption was not different for the two formulas, but nitrogen utilization was significantly better on Vital (28.6 +/- 12.9% versus 9.7 +/- 17.7%, p less than 0.01). This difference may be attributable to the different concentrations of sulfur-containing and aromatic amino acids in the two formulas.
Controlled trial comparing prednisolone with an elemental diet plus non-absorbable antibiotics in active Crohn's disease.Author Saverymuttu S; Hodgson HJ; Chadwick VS Source Gut, 26: 10, 1985 Oct, 994-8
In a randomised clinical trial, patients with moderately active Crohn's disease received either prednisolone 0.5 mg/kg/day plus a normal diet, or an elemental diet plus oral framycetin, colistin and nystatin. Patients were assessed using the Crohn's disease activity index (CDAI), ESR, and faecal granulocyte excretion quantified by 111In-autologous leucocytes. Five patients were intolerant of the elemental diet plus antibiotics and were withdrawn from the trial within 72 hours. Sixteen patients completed 10 days treatment on each regime. Fifteen of 16 patients on elemental diet plus antibiotics and all 16 patients on prednisolone improved with marked, but statistically indistinguishable falls in CDAI, ESR, and faecal granulocyte excretion between the two groups. Thus a regime decreasing the intraluminal concentration of bacteria and complex food molecules, was associated with rapid improvement in activity of Crohn's disease. This suggests that these intraluminal factors play a role in maintaining inflammation and that their removal or alteration offers an approach to management.
Comparison of total parenteral nutrition and elemental diet in induction of remission of Crohn's disease. Long-term maintenance of remission by personalized food exclusion diets.Author Jones VA Address Department of Community Medicine, East Anglian Regional Health Authority, Cambridge U.K. Source Dig Dis Sci, 32: 12 Suppl, 1987 Dec, 100S-107S Abstract Total parenteral nutrition or elemental diet can be used to induce remission of Crohn's disease. A randomized study has been conducted of 36 patients to assess the relative efficacy of the two techniques used without pharmacologic support; both were successful, and no significant differences emerged in the number of days to remission or the mean changes in Crohn's disease activity index, erythrocyte sedimentation rate, or serum albumin. The elemental diet is cheaper, simpler and safer. Uncontrolled clinical experience with 77 patients showed that personalized food exclusion diets were associated with an average annual relapse rate of only 11% for the first five years of diet alone; there have been six pregnancies and the longest remission is now 75 months. The use of elemental diet followed by the development of a personal food exclusion diet appears to be an effective long-term therapeutic strategy for Crohn's disease.
Chronic intermittent elemental diet improves growth failure in children with Crohn's disease.Author Belli DC; Seidman E; Bouthillier L; Weber AM; Roy CC; Pletincx M; Beaulieu M; Morin CL Address Service de Gastroentérologie, Hôpital Sainte-Justine, Québec, Canada. Source Gastroenterology, 94: 3, 1988 Mar, 603-10
Growth failure often complicates Crohn's disease in pediatric patients and is principally due to inadequate caloric intake. To assess whether intermittent courses of an elemental diet could reestablish growth, 8 children (aged 9.8-14.2 yr) with Crohn's disease and growth failure entered into a prospective trial. Each patient was studied during an observation year on standard therapy, then for an experimental year during which they received enteral elemental diet 1 out of 4 mo. An age- and disease-matched control group of 4 patients was treated by conventional medical therapy during both years. Elemental diet therapy was administered nocturnally, at home, by continuous nasogastric infusion and increased the daily caloric intake by 25% (p less than 0.01). Anthropometric measurements demonstrated significant height and weight gains in the elemental diet group vs. controls (p less than 0.01). Crohn's disease activity index and prednisone intake decreased significantly in patients receiving elemental diet therapy when compared with themselves and with controls on conventional medical therapy (p less than 0.05). In contrast, the rate of pubertal development was similar in both groups irrespective of the treatment modality. This study demonstrates that chronic intermittent elemental diet effectively reverses growth arrest, while decreasing prednisone requirements and Crohn's disease activity index in pediatric Crohn's disease patients prior to puberty.
Elemental diets in the prophylaxis and therapy for intestinal lesions: an update.Author Bounous G Address Department of Surgery, Montreal General Hospital, Quebec, Canada. Source Surgery, 105: 5, 1989 May, 571-5 Abstract The recognition of potentially noxious physiologic substances in the intestinal milieu prompted the use of an "elemental" semihydrolyzed formula diet in the prophylaxis of experimental acute ischemic enteropathy. Elemental diets have been used in the management of a variety of digestive diseases. An elemental diet protects the intestinal mucosa of rodents from radiation injury and facilitates mucosal healing. Clinical trials have shown the benefits of this form of treatment in the prevention of acute radiation enteropathy and in the therapy for delayed radiation enteropathy and Crohn's disease.
Steroids and bowel rest versus elemental diet in the treatment of patients with Crohn's disease: the effects on protein metabolism and immune function.Author O'Keefe SJ; Ogden J; Rund J; Potter P Address Gastrointestinal Clinic, Groote Schuur Hospital, South Africa. Source JPEN J Parenter Enteral Nutr, 13: 5, 1989 Sep-Oct, 455-60
Recent studies have shown an elemental diet to be as effective as bowel rest plus steroids in the management of acute Crohn's disease. In order to investigate the metabolic and immunological effects of these two therapies, six patients with an acute inflammatory attack of ileal Crohn's disease were randomly assigned to receive steroids or elemental diet for 7 days. Immunological and protein metabolic studies were performed before and after therapy, protein kinetic rates being measured by the method of constant intravenous infusion of 14C-labeled leucine tracer. Clinical and symptomatic improvement was noted in all six patients with significant falls in sedimentation rate and platelet counts and increases in albumin concentrations. Both forms of treatment increased plasma amino acid flux and oxidation rates, whole body protein turnover and rates of incorporation of amino acid into albumin. However, the increased rates of protein metabolism in the patients given steroids were at the expense of body protein stores with a net (average) loss of 58 g of nitrogen over 7 days. While both forms of therapy were associated with suppression of lymphocyte subsets, complement and circulating immune complexes only the steroid regimen was associated with suppression of in vivo IgG synthesis rates. The results indicated that both forms of therapy were associated with clinical improvement, increases in protein turnover and evidence of reduced inflammatory activity. However, the beneficial effects of steroid regimen must be balanced against the deleterious effects on body protein stores; steroids and bowel rest without nutritional support should be avoided in malnourished patients.
Improvement of abnormal lactulose/rhamnose permeability in active Crohn's disease of the small bowel by an elemental diet.Author Sanderson IR; Boulton P; Menzies I; Walker-Smith JA Address Department of Child Health, St. Bartholomew's Hospital, London. Source Gut, 28: 9, 1987 Sep, 1073-6
Intestinal permeability to sugar has been used as an objective measure of small bowel integrity to assess the efficacy of an elemental diet as the sole treatment or Crohn's disease of the small bowel. Fourteen children aged 11-17 years with active small bowel Crohn's disease were given an elemental diet for six weeks. Investigations with iso-osmolar oral test solutions before and after this treatment showed that all 14 children had abnormally raised lactulose/L-rhamnose permeability ratios, which fell significantly after the elemental diet. This change coincided with marked clinical improvement, as assessed by a disease activity index score.
Clinical remission and disappearance of radiologic manifestations in Crohn's disease after oligopeptide diet treatment.Author Pfeil AB; Schuster AT; Kemperdick H Address Department of Pediatrics, University of Düsseldorf, F.R.G. Source J Pediatr Gastroenterol Nutr, 7: 6, 1988 Nov-Dec, 926-30 Abstract A 9.6-year-old patient was treated exclusively with an oligopeptide diet at initial diagnosis and at first relapse of Crohn's ileocolitis. The patient achieved complete remission in both episodes. Control radiologic examinations 14 months after diagnosis revealed complete disappearance of radiologic manifestations of Crohn's disease.
Diet counseling modifies nutrient intake of patients with Crohn's disease.Author Imes S; Pinchbeck BR; Thomson AB Source J Am Diet Assoc, 87: 4, 1987 Apr, 457-62
The nutrient intake of 137 outpatients with Crohn's disease was recorded, and the effect of diet counseling was assessed. Half the patients received monthly diet counseling that was individualized and aimed at normalizing nutrient intake; the other half of the patients received no diet counseling and served as controls. Over the 6-month study period, the mean nutrient intakes met or exceeded the 1980 U.S. Recommended Dietary Allowances (RDAs) for all nutrients except folate in the men and iron and folate in the women. However, at study entry, for each nutrient there was a substantial proportion of patients whose intake did not meet the full RDA. Less than 50% of the men consumed the full RDA for energy and folate, and less than 50% of the women consumed the full RDA for energy, folate, calcium, iron, thiamin, and vitamin B-12. Monthly diet counseling sessions were associated with increases in the mean intake of most nutrients, whereas similar improvement was not observed in the control group members, who did not receive counseling. By 6 months, significantly more counseled than non-counseled patients were consuming the full RDA for protein, riboflavin, and vitamin C (p less than .05). Thus, diet counseling was found to be an important tool for improving the nutrient intake of outpatients with Crohn's disease.
Diet and bowel diseases--past history and future prospects.Author Walker AR Source S Afr Med J, 68: 3, 1985 Aug 3, 148-52 Abstract Changes in diet from ancient times until the present are described. Previously relatively low in energy and animal products yet high in fibre-containing foods, diets are now high in energy and animal products (particularly fat), yet contain less fibre. The changing incidences of bowel disorders and diseases are described, with assessments of the role of diet. Clearly, diet is implicated as regards predisposition to constipation, appendicitis, colorectal cancer and diverticular disease; however, a meaningful dietary role in irritable bowel syndrome, ulcerative colitis and Crohn's disease is doubtful. In South Africa the rarity of bowel diseases in rural blacks compared with whites affords valuable aetiological information about some bowel diseases. The low occurrence thereof (except inflammatory bowel disease) in Indian and coloured populations is not readily explicable. While dietary changes in whites are being widely urged in order to combat degenerative diseases, the magnitude of changes made is unlikely to reduce the occurrence of bowel diseases. The progressive westernization of the diets and lifestyles of less-privileged populations is likely to be associated with increases in the incidences of these diseases.
Home enteral nutrition with formula diets.Author Russell RI Source Z Gastroenterol, 23 Suppl:1985 Aug, 94-7
Home enteral nutrition can be successfully used on a long-term basis to maintain nutrition and a reasonably normal lifestyle in patients with chronic intestinal dysfunction. Patients can be easily taught the methods involved, a nocturnal regime allowing a more normal lifestyle. The use of a pump-controlled system is recommended. Side-effects are few, generally transient and not severe. Home enteral nutrition has advantages over home intravenous feeding with respect to ease of administration and organisation, fewer and less severe complications, and cost.
Iron, folate, vitamin B-12, zinc, and copper status in outpatients with Crohn's disease: effect of diet counseling.Author Imes S; Pinchbeck BR; Dinwoodie A; Walker K; Thomson AB Source J Am Diet Assoc, 87: 7, 1987 Jul, 928-30
Iron, folate, and vitamin B-12 status was found to be poor in a substantial proportion of outpatients with generally inactive Crohn's disease. Diet counseling was associated with a normalization of TIBC and serum folate over a 6-month period, but no other consistent benefits were noted despite moderate improvements in intake. The outpatients appeared to be at low risk of developing a zinc or copper deficiency.
Crohn's disease: maintenance of remission by diet.Author Jones VA; Dickinson RJ; Workman E; Wilson AJ; Freeman AH; Hunter JO Source Lancet, 2: 8448, 1985 Jul 27, 177-80 Abstract 20 patients with Crohn's disease took part in a controlled trial in which remission was maintained by either an unrefined carbohydrate fibre rich diet or a diet which excluded specific foods to which a patient was intolerant. 7 out of the 10 patients on the exclusion diet remained in remission for 6 months compared with none out of the 10 on an unrefined carbohydrate fibre rich diet (p less than 0.05, Fisher's exact test). In an uncontrolled study an exclusion diet allowed 51 out of 77 patients to remain well on the diet alone for periods of up to 51 months, and with an average annual relapse rate of less than 10%.
Diet counselling improves the clinical course of patients with Crohn's disease.Author Imes S; Pinchbeck B; Thomson AB Address Nutrition and Metabolism Research Group, Faculty of Medicine, University of Alberta, Edmonton, Canada. Source Digestion, 39: 1, 1988, 7-19
A prospective study was undertaken to establish the role of individualized diet counselling in the management of 137 outpatients with Crohn's disease. Individualized dietary counselling for 6 months was associated with a significant decrease in the Crohn's disease activity index, an increased incidence of disease remission, a decreased need for prednisone and Salazopyrin therapy, a reduction in the number of days spent in hospital, and a reduction in the amount of time lost from work due to Crohn's disease, when compared with control patients who did not receive dietary counselling but who were seen regularly in follow-up under similar circumstances. Improvement with diet counselling was more likely to occur in patients who had not previously been subjected to small bowel resection, and occurred in patients with active or inactive disease. The effect of counselling 58 patients was assessed over a further 6 months (for a total 12-month period); there was a persistently reduced Crohn's disease activity index and a continued decreased number of lost days of work. The mechanism for these beneficial effects of diet counselling was not established. It is suggested that individualized diet counselling, aimed at optimizing the patient's nutritional status, may play a role in the management of patients with Crohn's disease.
Vitamin C status in 137 outpatients with Crohn's disease. Effect of diet counseling.Author Imes S; Dinwoodie A; Walker K; Pinchbeck B; Thomson AB Source J Clin Gastroenterol, 8: 4, 1986 Aug, 443-6
Vitamin C intake, and serum and leukocyte ascorbate levels were assessed serially over 6 months in 137 outpatients with Crohn's disease. Vitamin C intake was low in 18% of males and 37% of females. Serum ascorbate levels were suboptimal in 11% of males and 18% of females. Leukocyte ascorbate levels were low in 26% of males and 49% of females. Serum ascorbate levels were more frequently below the reference range in patients who smoked, but neither the serum nor the leukocyte ascorbate levels were affected by Crohn's disease activity, the use of an oral contraceptive agent, or by taking prednisone or sulfasalazine. Monthly diet counseling sessions significantly increased vitamin C intake, led to more patients consuming a normal ascorbate intake, and to a normalization of serum ascorbate values. We did not establish the importance of these ascorbate abnormalities on the clinical course of Crohn's disease. We conclude that low serum or leukocyte ascorbate levels are relatively common in patients with active or inactive Crohn's disease; these abnormalities are due in part to the reduced intake of dietary ascorbate; and the ascorbate status in patients with Crohn's disease may be normalized by improving the dietary intake of vitamin C.
Remission induced by an elemental diet in small bowel Crohn's disease.Author Sanderson IR; Udeen S; Davies PS; Savage MO; Walker-Smith JA Source Arch Dis Child, 62: 2, 1987 Feb, 123-7
Seventeen children with active Crohn's disease of the small intestine were entered into a randomised control trial comparing the efficacy of an elemental diet with that of a high dose steroid regimen. Eight children received an elemental diet (Flexical) through a nasogastric tube for six weeks, followed by reintroduction of food over six weeks during which the Flexical was stopped. Seven children were given intramuscular adrenocorticotrophic hormone followed by oral prednisolone with sulphasalazine. Two children were withdrawn from the trial. The elemental diet was equally effective in inducing an improvement in Lloyd-Still disease activity index, erythrocyte sedimentation rate, C reactive protein and albumin concentrations, and body weight as the high dose steroid regimen. Linear growth, assessed from height velocity over six months, was significantly greater in the children receiving an elemental diet.
Elemental diet administered nasogastrically without starter regimens to patients with inflammatory bowel disease.Author Rees RG; Keohane PP; Grimble GK; Frost PG; Attrill H; Silk DB Source JPEN J Parenter Enteral Nutr, 10: 3, 1986 May-Jun, 258-62 Abstract The present study questions the concept of routinely using 'starter regimens' at the outset of enteral feeding with chemically defined elemental diets. A hypertonic elemental diet with an osmolality of 630 mOsm/kg was administered by 24-hr nasogastric infusion to 12 patients with exacerbations of inflammatory bowel disease and to two patients with short bowel syndrome. Starter regimens were not used. Upper gastrointestinal symptoms of nausea, abdominal bloating, and colicky pain occurred transiently in only five of 14 patients. Stool frequency did not increase during full-strength feeding, and daily stool weights decreased significantly (p less than 0.01). These findings show that it is safe to administer undiluted hypertonic elemental diets by constant nasogastric infusion to patients with inflammatory bowel disease. Avoiding starter regimens leads to increased nutrient intake and improved nitrogen balance.
Controlled trial comparing an elemental diet with prednisolone in the treatment of active Crohn's disease.Author Okada M; Yao T; Yamamoto T; Takenaka K; Imamura K; Maeda K; Fujita K Address 1st Department of Internal Medicine, School of Medicine, Fukuoka University, Japan. Source Hepatogastroenterology, 37: 1, 1990 Feb, 72-80 Abstract To determine whether an elemental diet or prednisolone would be more effective for treating acute Crohn's disease, a controlled trial was conducted on 20 patients with acute Crohn's disease who had never received specific treatment. The first ten patients were put on an elemental diet and the remaining ten were prescribed prednisolone for six weeks at an initial dose of 0.7 mg/kg/day. Patients were assessed using the simple activity index, body weight, erythrocyte sedimentation rate, C-reactive protein and alpha 2 globulin, serum albumin, and radiographic findings of bowel lesions. At six weeks, the patients on the elemental diet showed a significantly greater improvement in the activity index, inflammatory signs such as C-reactive protein and alpha 2 globulin, and radiographic findings of bowel lesions than did those on the steroid. Patients who were given steroids for six weeks and then treated with the elemental diet for four weeks showed improvement in the radiographic findings of bowel lesions and inflammation. The present study strongly suggests that elemental diet is superior to steroids for treating active Crohn's disease.
Ten years' experience with an elemental diet in the management of Crohn's disease.Author Teahon K; Bjarnason I; Pearson M; Levi AJ Address Section of Gastroenterology, MRC Clinical Research Centre, Harrow, Middlesex, UK. Source Gut, 31: 10, 1990 Oct, 1133-7 Abstract The immediate and long-term outcome of treating patients with acute Crohn's disease with an elemental diet was studied retrospectively. Successful diet induced remission was achieved in 96 of 113 patients (85%) regardless of age, sex, site or severity of disease, or associated complications of strictures, fistula, or perianal disease. Treatment was unsuccessful in 17 patients (15%), but there were no features at the outset of treatment that distinguished these patients from those who had successful remission. The longterm outcome of treatment was assessed over a five year period by analysis of life tables and survival curves. Twenty two per cent of the patients relapsed within six months of treatment and thereafter the annual relapse rate was 8-10%. Patients with disease complicated by fistula or perianal involvement had early relapse, approaching 100% for the latter. A further retrospective comparison of longterm outcome of diet vs steroid induced remissions showed no significant difference in the relapse rates between the two groups at one, three, and five years.
Controlled trial of polymeric versus elemental diet in treatment of active Crohn's diseaseAuthor Giaffer MH; North G; Holdsworth CD Address Gastroenterology Unit, Royal Hallamshire Hospital, Sheffield. Source Lancet, 335: 8693, 1990 Apr 7, 816-9
30 patients with active Crohn's disease, mean Crohn's Disease Activity Index 301 (SE 32), who would otherwise have been treated with steroids, were randomised to receive for 4 weeks either an elemental diet ('Vivonex') (n = 16) or a polymeric diet ('Fortison') (n = 14). Assessment on days 10 and 28 showed that clinical remission occurred in 5 (36%) of the 14 patients on fortison compared with 12 (75%) of the 16 patients assigned to vivonex. The difference in remission rate was significant (p less than 0.03). Dietary treatment resulted in little change in the nutritional state and various laboratory indices of activity over a 4 week period despite clinical improvement. Polymeric diets do not seem to offer an effective therapeutic alternative to elemental diets in patients with acute exacerbations of Crohn's disease.
Feasibility and effectiveness of a defined-formula diet regimen in treating active Crohn's disease. European Cooperative Crohn's Disease Study III.Author Malchow H; Steinhardt HJ; Lorenz-Meyer H; Strohm WD; Rasmussen S; Sommer H; Jarnum S; Brandes JW; Leonhardt H; Ewe K; et al Address Medizinische Klinik II, Staedtisches Krankenhaus (Dhuennberg), Leverkusen 1, FRG. Source Scand J Gastroenterol, 25: 3, 1990 Mar, 235-44
In a randomized multicenter trial the efficacy of treatment of active Crohn's disease by means of a liquid defined formula diet (DFD) was tested and compared with a combination of 6-methyl-prednisolone and sulfasalazine. A total of 95 patients participated in the study. By the end of 6 weeks, among 44 patients randomized to drug treatment, 32 showed improvement of the Crohn's disease activity index (CDAI) as compared with 21 of 51 patients receiving oral DFD (p less than 0.05). The proportion of withdrawals in the DFD group (29 of 51) was sevenfold higher than in the drug group (4 of 44). However, most patients (20 of 29) receiving DFD withdrew because of the unpalatability of the liquid diet. Analysis of patients in each group who finished the study showed equal effectiveness of DFD and the drug regimen. In these subsets of patients the CDAI decreased from 280.8 +/- 90.6 to 151.7 +/- 86.5 (DFD) and from 263.7 +/- 86.3 to 129.3 +/- 63.7 (drug), respectively. Improvement of inflammation factors was similar in both groups at the end of the study, although improvement was delayed in the DFD group. In conclusion, our data show a superiority of the drug combination over DFD in the treatment of Crohn's disease under the conditions of this trial. The results do suggest, however, that DFD offers a therapeutic alternative to prednisolone and sulfasalazine in a subgroup of patients, which has to be closer characterized in further studies.
The effect of elemental diet on intestinal permeability and inflammation in Crohn's disease.Author Teahon K; Smethurst P; Pearson M; Levi AJ; Bjarnason I Address Section of Gastroenterology, Medical Research Council Clinical Research Centre, Harrow, Middlesex, England. Source Gastroenterology, 101: 1, 1991 Jul, 84-9 Abstract This study examines whether treatment of acute Crohn's disease with an elemental diet improves intestinal integrity and inflammation as assessed by a 51Cr-labeled ethylenediaminetetraacetatic acid (EDTA) permeability test and the fecal excretion of 111In-labeled autologous leukocytes, respectively. Thirty-four patients with active Crohn's disease completed a 4-week treatment course with an elemental diet. Active disease was characterized by increased intestinal permeability [24-hour urine excretion of orally administered 51Cr-EDTA, 6.4% +/- 0.6% (mean +/- SE); normal, less than 3.0%] and by high fecal excretion of 111In-labeled leukocytes (14.2% +/- 1.1%; normal, less than 1.0%). Twenty-seven (80%) went into clinical remission, usually within a week of starting treatment. After 4 weeks of treatment, there was a significant decrease in both the urine excretion of 51Cr-EDTA (to 3.4% +/- 0.5%; P less than 0.01) and the fecal excretion of 111In (to 5.7% +/- 1.0%; P less than 0.001), indicating that such treatment is not just symptomatic. A framework for the mechanism by which elemental diet works, centering around the importance of the integrity of the intestinal barrier function, is proposed, and also appears to provide a logical explanation for some relapses of the disease.
Long-term effects of elemental and exclusion diets for Crohn's disease.Author Giaffer MH; Cann P; Holdsworth CD Address Royal Hallamshire Hospital, Sheffield, UK. Source Aliment Pharmacol Ther, 5: 2, 1991 Apr, 115-25
Previous studies have confirmed the therapeutic value of elemental diets in promoting remission in active Crohn's disease, but their long-term benefit has not been established. Twenty-seven patients with established Crohn's disease who attained clinical remission after four weeks of enteral feeding were followed prospectively for up to 36 months. Twenty of these were willing to be tested for specific food intolerance using a pre-defined dietary elimination protocol; the others continued on a normal unrestricted diet. Eighteen patients (67%) have since relapsed; 89% of the relapse occurred within the first 6 months. Of the 15 patients with colonic involvement, 12 (80%) relapsed by 6 months. In contrast only 3 of 11 with isolated small bowel disease experienced early relapse. Of the 14 patients who completed the process of dietary testing, 5 could not identify any trigger foods; the remaining 9 were maintained on exclusion diets, 3 of whom relapsed early. Of the 11 taking a normal diet, 9 relapsed. Disease duration, previous intestinal resection or prior steroid therapy did not affect the relapse rate. Eight patients (31%) obtained a long-term remission, mean 23 months (range 12-36 months), without any medication. Long-lasting remissions can be obtained in about one-third of patients with Crohn's disease following treatment with a defined formula diet. Colonic involvement is associated with a high early relapse rate.
Elemental diet in the management of Crohn's disease during pregnancy.Author Teahon K; Pearson M; Levi AJ; Bjarnason I Address Section of Gastroenterology, MRC Clinical Research Centre, Middlesex. Source Gut, 32: 9, 1991 Sep, 1079-81
Four patients with Crohn's disease were treated with an elemental diet during pregnancy. Two had active disease and two also had symptoms of small intestinal obstruction. All went into a clinical remission within a few days of starting treatment. Treatment periods varied from two to four weeks, and were followed by elemental diet as a supplement to normal food in two patients. At term, all delivered a healthy infant. These patients indicate that elemental diet is a safe form of treatment for Crohn's disease during pregnancy and may be considered as an alternative to conventional drug treatments which carry a theoretical risk of teratogenesis.
Elemental diet in steroid-dependent and steroid-refractory Crohn's disease.Author O'Brien CJ; Giaffer MH; Cann PA; Holdsworth CD Address Gastroenterology Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom. Source Am J Gastroenterol, 86: 11, 1991 Nov, 1614-8
Sixteen patients with Crohn's disease who had symptoms uncontrolled by high-dose steroids (n = 11) or symptoms invariably appearing on reduction or withdrawal of immunosuppressive therapy (n = 5) were treated with elemental diet. After 4 wk of dietary treatment, 10 patients were in remission and off all medication. Seven continued to be well without treatment for a minimum of 6 months, and four for at least 1 yr. No patient who subsequently relapsed had further steroid-refractory symptoms. Of the six patients failing to respond to elemental diet, four with steroid-refractory disease required early resective surgery for symptom relief, and two continued with steroid therapy, one in much reduced dosage. Elemental diet can bring about a sustained remission in many patients with Crohn's disease dependent on or refractory to corticosteroids, and reduce the need for surgical intervention.
Improved growth and disease activity after intermittent administration of a defined formula diet in children with Crohn's disease.Author Polk DB; Hattner JA; Kerner JA Jr Address Department of Pediatrics, Stanford University School of Medicine, California. Source JPEN J Parenter Enteral Nutr, 16: 6, 1992 Nov-Dec, 499-504 Abstract Growth failure is the most common extraintestinal manifestation of Crohn's disease in childhood, occurring in up to 50% to 88% of affected patients. Previous studies have shown malnutrition to be the most likely cause of the decrease in height and weight velocities in these children. The purpose of this study was to determine the effect of an intermittent defined formula diet on growth and disease activity in children with Crohn's disease and growth failure. Six Tanner stage I-II patients, mean age 13.6 years with height less than the 5th percentile or height velocity less than the 3rd percentile were enrolled in a 1-year prospective study. An isotonic, hydrolyzed whey, medium-chain triglyceride formula was given by nocturnal nasogastric infusion at a caloric equivalent of 50th percentile for age, as the exclusive nutrient source 1 out of 4 months during a 1-year period. A 2-week exclusion diet and a 2-week low-residue diet followed the defined formula diet before resuming the regular diet for 2 months. Patients served as their individual control based on observations of at least 1 year before the study. Height and weight velocity significantly increased. Prednisone intake significantly decreased, and significant improvement was seen in disease activity, albumin, and somatomedin C. The results indicate that an intermittent defined formula diet can improve growth failure and significantly decrease disease activity in children with Crohn's disease.
Diet and inflammatory bowel disease: a case-control study.Author Persson PG; Ahlbom A; Hellers G Address Department of Epidemiology, Karolinska Institutet, Stockholm, Sweden. Source Epidemiology, 3: 1, 1992 Jan, 47-52
We conducted a population-based case-control study of inflammatory bowel disease and dietary habits in Stockholm during 1984-1987. We obtained retrospective information about food intake 5 years previously by a postal questionnaire for 152 cases with Crohn's disease, 145 cases with ulcerative colitis, and 305 controls. The relative risk of Crohn's disease was increased for subjects who had a high (55 gm or more per day) intake of sucrose (relative risk = 2.6, 95% confidence interval = 1.4-5.0) and was decreased for subjects who had a high (15 gm or more per day) intake of fiber (relative risk = 0.5, 95% confidence interval = 0.3-0.9). The most striking finding was an increased relative risk of both Crohn's disease and ulcerative colitis associated with consumption of fast foods: the relative risk associated with consumption of fast foods at least two times a week was estimated at 3.4 (95% confidence interval = 1.3-9.3) for Crohn's disease and 3.9 (95% confidence interval = 1.4-10.6) for ulcerative colitis.
Initial response and subsequent course of Crohn's disease treated with elemental diet or prednisolone.Author Gorard DA; Hunt JB; Payne-James JJ; Palmer KR; Rees RG; Clark ML; Farthing MJ; Misiewicz JJ; Silk DB Address Department of Gastroenterology, St Bartholomew's Hospital, London. Source Gut, 34: 9, 1993 Sep, 1198-202 Abstract Elemental diet is as effective as corticosteroids in the treatment of previously untreated Crohn's disease. It is unclear whether a poor nutritional state is a prerequisite for efficacy of elemental diet, whether previously treated patients respond as well, or how duration of remission using elemental diet compares with corticosteroid induced remission. Forty two patients with active Crohn's disease were stratified for nutritional state and randomised to receive Vivonex TEN 2.1 l/day for four weeks, or 0.75 mg prednisolone/kg/day for two weeks and subsequent reducing doses. Nine of 22 (41%) patients assigned to nutritional treatment were intolerant of the diet. Thirty patients completed four weeks treatment. Disease activity decreased on elemental diet from mean (SEM) 4.8 (0.9) to 1.7 (0.6), p < 0.05, and on prednisolone from 5.3 (0.5) to 1.9 (0.6), p < 0.05. For each treatment, nourished and malnourished patients responded similarly. Patients with longstanding disease responded as well as newly diagnosed patients. The probability of maintaining remission at six months was 0.67 after prednisolone, 0.28 after elemental diet, and at one year was 0.35 after prednisolone and 0.09 after elemental diet, p < 0.05. When tolerated, elemental diet is as effective in the short term as prednisolone in newly and previously diagnosed Crohn's disease, and its benefit is independent of nutritional state. The subsequent relapse rate after elemental diet induced remission, however, is greater than after treatment with prednisolone.
Comparison of amino acid v peptide based enteral diets in active Crohn's disease: clinical and nutritional outcome.Author Royall D; Jeejeebhoy KN; Baker JP; Allard JP; Habal FM; Cunnane SC; Greenberg GR. Division of Gastroenterology, Toronto General Hospital, Canada. Source Gut, 35: 6, 1994 Jun, 783-7
Elemental diets are considered an effective primary treatment for active Crohn's disease. This study examined the hypothesis that improvement occurs because of the presence of amino acids or the low fat content, or both. A randomised, controlled trial was undertaken in 40 patients with active Crohn's disease to evaluate clinical and nutritional outcomes after an amino acid based diet containing 3% fat was given by a feeding tube compared with a peptide based diet containing 33% fat. After three weeks' treatment, clinical remission occurred in 84% of patients who were given the amino acid diet and 75% of patients who received the peptide diet (p = 0.38). Plasma linoleic acid concentration was reduced after the amino acid but not the peptide diet. An increase in total body nitrogen was associated with the magnitude of nutritional depletion before treatment and at six months' follow up, only patients who showed gains in total body nitrogen after enteral nutrition had a sustained clinical remission. This study shows that peptide based high fat diets are as effective as amino acid low fat diets for achieving clinical remission in active Crohn's disease. Improved total body protein stores but not essential fatty acid depletion may be an important indicator of a sustained remission.
Treatment of active Crohn's disease by exclusion dietAuthor Riord an AM; Hunter JO; Cowan RE; Crampton JR; Davidson AR; Dickinson RJ; Dronfield MW; Fellows IW; Hishon S; Kerrigan GN; et al Address Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK. Source Lancet, 342: 8880, 1993 Nov 6, 1131-4 Abstract Elemental diet is as effective in producing remission of Crohn's disease (CD) as is corticosteroid treatment, but most patients relapse soon after resumption of a normal diet. We have investigated the efficacies of dietary modification and oral corticosteroids in maintaining remission achieved with elemental diet. In a multicentre trial, 136 patients with active CD were started on elemental diet and other treatment was withdrawn. 43 (31%) declined to continue elemental diet for 14 days, but 78 (84%) of the remaining 93 achieved remission and were randomly assigned corticosteroids (38) or diet (40). Corticosteroid treatment started at 40 mg prednisolone daily, which was tapered and stopped after 12 weeks; that group received dietary advice on healthy eating. The diet group received "tapered" placebo and were instructed to introduce one new food daily, excluding any that precipitated symptoms. Assessment of progress for up to 2 years was made by physicians unaware of group assignment. Intention-to-treat analysis showed median lengths of remission of 3.8 (interquartile range 5.0) months in the corticosteroid group and 7.5 (15.3) months on diet, and relapse rates at 2 years, adjusted for withdrawals, of 79% and 62%, respectively (p = 0.048). Clinical improvement in the diet group was associated with significant changes in plasma albumin and alpha 1-antichymotrypsin concentrations and erythrocyte sedimentation rate. Food intolerances discovered were predominantly to cereals, dairy products, and yeast. Diet provides a further therapeutic strategy in active Crohn's disease.
Alterations in nutritional status and disease activity during treatment of Crohn's disease with elemental diet.Author Teahon K; Pearson M; Smith T; Bjarnason I Address Dept. of Clinical Pharmacology, University of Newcastle-upon-Tyne, UK. Source Scand J Gastroenterol, 30: 1, 1995 Jan, 54-60
The mechanisms by which elemental diets induce remission in patients with Crohn's disease is unknown, but it has been suggested that improvement in nutritional state may play a part. METHODS: We assessed sequential changes in disease activity (clinical and laboratory indices and faecal excretion of indium-111-labelled leucocytes) and nutritional status (anthropometry, body composition variables), hepatic secretory proteins (albumin, pre-albumin, transferrin), and trace elements (iron, magnesium, copper, zinc) during treatment of acute Crohn's disease with an elemental diet. RESULTS: Disease activity indices improved significantly by 2 weeks and were maintained at 4 weeks of treatment. There was a significant increase in pre-albumin at 4 weeks and an increase in serum iron and a decrease in serum copper during the study period. The changes occurring in the measures of nutrition did not correlate significantly with the changes in disease activity. CONCLUSION: The fact that changes in disease activity appear to precede any detectable changes in nutritional state, it suggests that the beneficial action of elemental diet in patients with active Crohn's disease is not due to an improvement in nutritional status.
Remission following an elemental diet or prednisolone in Crohn's disease.Author Papadopoulou A; Rawashdeh MO; Brown GA; McNeish AS; Booth IW Address University of Birmingham, Institute of Child Health, UK. Source Acta Paediatr, 84: 1, 1995 Jan, 79-83
The short- and long-term effects of an elemental diet in children with acute Crohn's disease were compared with those of prednisolone in historical controls. Clinical remission was induced in 25 of 30 and in 18 of 28 episodes treated for six weeks with an elemental diet and prednisolone. Patients with proximal disease had longer remission after treatment with an elemental diet (p < 0.05) than did patients with colonic disease after treatment with prednisolone (p < 0.01). Disease activity index score improved in both groups compared with the pretreatment scores (p < 0.05). However, the improvement in the elemental diet group was significantly better than in the prednisolone group (p < 0.001). Changes in linear growth were better after treatment with an elemental diet compared with steroids (p < 0.001). Serum albumin and haematocrit concentrations all improved significantly in the children treated with an elemental diet (p < 0.001) but not in those treated with steroids. Thus an elemental diet was better than prednisolone in proximal disease and confirmed improved growth and nutritional status.
Controlled trial of oligopeptide versus amino acid diet in treatment of active Crohn's disease.Author Mansfield JC; Giaffer MH; Holdsworth CD Address Gastroenterology Unit, Royal Hallamshire Hospital, Sheffield. Source Gut, 36: 1, 1995 Jan, 60-6
Elemental diets are effective in inducing remission in active Crohn's disease, but how they exert this therapeutic effect is unclear. In a previous study a whole protein containing diet proved less effective than one in which food antigens were excluded, suggesting that exclusion of food antigens from the gut was a possible mechanism. This study was designed to test whether an oligopeptide diet of hydrolysed proteins was as effective as an amino acid based diet. These diets were equally antigen free but with different nitrogen sources. Forty four patients with active Crohn's disease were randomised in a controlled trial of amino acid versus oligopeptide diet. The feeds were given by nasogastric tube in equicaloric quantities and were the sole form of nutrition. Treatment was continued for four weeks although failure to improve by day 10 resulted in withdrawal. Quantitative leucocyte scintigraphy was used to investigate the effect of diet treatment on gut inflammation. Clinical and nutritional responses to treatment were also measured. Sixteen patients entered remission (including withdrawal of corticosteroids), six patients could not tolerate the nasogastric tube, and 22 patients failed to respond. The two diets were equally effective. Patients who responded had a rapid drop in clinical index of disease activity and a major reduction in the bowel uptake of leucocytes on scintigraphy. The oligopeptide and amino acid based enteral feeds were equally effective at inducing remission in active Crohn's disease. With both diets clinical improvement was accompanied by a reduction in intestinal inflammation.
Polymeric enteral diets as primary treatment of active Crohn's disease: a prospective steroid controlled trial.Author González-Huix F; de León R; Fernández-Bañares F; Esteve M; Cabré E; Acero D; Abad-Lacruz A; Figa M; Guilera M; Planas R; et al Source Gut, 34: 6, 1993 Jun, 778-82
Thirty two patients with active Crohn's disease were included in a controlled randomised trial to determine the efficacy and safety of polymeric enteral nutrition compared with steroids, to achieve and maintain clinical remission. The polymeric diet was administered through a fine bore nasogastric tube by continuous, pump assisted infusion (2800 (SEM 120) kcal/day). The steroid group received 1 mg/kg/day of prednisone. Both treatments were effective in inducing clinical remission: 15 of the 17 patients given steroids and 12 of the 15 patients assigned to the polymeric diet went into clinical remission (defined by a Van Hees index < 120) within four weeks of treatment. The percentage reduction of the Van Hees index was 34.8 (4.9)% for steroids and 32.3 (5)% for enteral nutrition (mean difference 2.5%; 95% CI--11.8% to +16.8%). Mean time elapsed to achieve remission was similar in both groups (2.0 (1) v 2.4 (1.2) weeks). Tolerance of the enteral diet was excellent. Four patients in the steroid group had mild complications attributable to this treatment. Ten patients (66.6%) in the steroid group and five (41.6%) in the enteral nutrition group relapsed within a year of discharge, but no differences were found in the cumulative probability of relapse during the follow up period. These results suggest that polymeric enteral nutrition is as safe and effective as steroids in inducing short term remission in active Crohn's disease.
Comparison between the bacterial and oligosaccharide content of ileostomy effluent in subjects taking diets rich in refined or unrefined carbohydrate.Author Berghouse L; Hori S; Hill M; Hudson M; Lennard-Jones JE; Rogers E Source Gut, 25: 10, 1984 Oct, 1071-7 Abstract Dietary surveys have shown that patients with Crohn's disease tend to eat more sucrose than control subjects and this investigation was undertaken to determine whether a diet rich in refined carbohydrate affects the bacterial flora of the terminal ileum. Ileostomy effluent in five patients with Crohn's disease and five with ulcerative colitis after two weeks on a diet rich in sucrose and refined cereal has been compared with the same period on a diet low in sucrose and rich in unrefined cereal. Observations were made hourly for nine hours after equicaloric breakfasts representing the two diets. The amount of ileostomy effluent was greater on the unrefined carbohydrate diet both in terms of wet weight (238 +/- 89 g vs 162 +/- 79 g, p less than 0.02) and dry weight (23 X 6 +/- 6.8 g vs 14.9 +/- 6.6 g, p less than 0.01); surprisingly, the amount of glucose and oligosaccharide was also greater (169 +/- 41 mg vs 82 +/- 26 mg, p less than 0.001) in all 10 volunteers. The bacteriological flora per gram was also higher on the unrefined carbohydrate diet after the test meal (p less than 0.02 between three and six hours) as a result of a general increase in all organisms. The relative proportions of the organisms did not vary between the two diets. No differences were detected between patients with ulcerative colitis and those with Crohn's disease.
The gut as a lymphoepithelial organ: the role of intestinal epithelial cells in mucosal immunity.Author TlaskalovÆa-HogenovÆa H; FarrÆe-Castany MA; StÅepÆankovÆa R; KozÆakovÆa H; TuÅckovÆa L; Funda DP; Barot R; Cukrowska B; Sinkora J; Mandel; L; et al. Source Folia Microbiol (Praha), 1995, 40:4, 385-91
Mucosal surfaces covered by a layer of epithelial cells represent the largest and most critical interface between the organism and its environment. The barrier function of mucosal surfaces is performed by the epithelial layer and immune cells present in the mucosal compartment. As recently found, epithelial cells, apart from their participation in absorptive, digestive and secretory processes perform more than a passive barrier function and are directly involved in immune processes. Besides the well known role of epithelial cells in the transfer of polymeric immunoglobulins produced by lamina propria B lymphocytes to the luminal content of mucosals (secretory Igs), these cells were found to perform various other immunological functions, to interact with other cells of the immune system and to induce an efficient inflammatory response to microbial invasion: enzymic processing of dietary antigens, expression of class I and II MHC antigens, presentation of antigens to lymphocytes, expression of adhesive molecules mediating interaction with intraepithelial lymphocytes and components of extracellular matrix, production of cytokines and probable participation in extrathymic T cell development of intraepithelial lymphocytes. All these functions were suggested to influence substantially the mucosal immune system and its response. Under immunopathological conditions, e.g. during infections and inflammatory bowel and celiac diseases, both epithelial cells and intraepithelial lymphocytes participate substantially in inflammatory reactions. Moreover, enterocytes could become a target of mucosal immune factors. Mucosal immunosurveillance function is of crucial importance in various pathological conditions but especially in the case of the most frequent malignity occurring in the intestinal compartment, i.e. colorectal carcinoma. Proper understanding of the differentiation processes and functions of epithelial cells in interaction with other components of the mucosal immune system is therefore highly desirable.
Milk hypersensitivity--key to poorly defined gastrointestinal symptoms in adults.
Author Pelto L; Salminen S; Lilius EM; Nuutila J; Isolauri E. Source Allergy, 1998 Mar, 53:3, 307-10
Lactose intolerance is a common adverse reaction to milk in adults, while milk hypersensitivity is a disorder of infancy. We hypothesized that milk hypersensitivity may cause many unspecific gastrointestinal disorders in adults. Twenty adults were subjected to double-blind, placebo-controlled milk challenge. Phagocyte activity, and Fc gamma and complement receptor expression of phagocytes were assayed, and serum total IgE, milk-specific IgE, and serum reactivity to milk protein were determined. The challenge increased phagocyte activity and complement receptor expression of phagocytes in subjects designated milk-hypersensitive, who had gastrointestinal symptoms from milk ingestion but normal lactose tolerance. The increase was not detected in lactose-intolerant or control subjects. The milk-hypersensitive group was also distinguished from the lactose-intolerant group by enhanced serum reactivity to milk protein. Only two out of nine milk-hypersensitive subjects had detectable milk-specific serum IgE. It is concluded that milk hypersensitivity in adults, occurring as gastrointestinal reactions, may be more common than previously thought.